What is the best questionnaire for screening dementia?

Best Questionnaires for Dementia Screening

The Montreal Cognitive Assessment (MoCA) is the recommended screening tool for dementia, particularly when mild cognitive impairment is suspected or when there is concern about cognitive status despite a "normal" MMSE score. 1

Primary Screening Tools Comparison

Montreal Cognitive Assessment (MoCA)

• More sensitive than MMSE for detecting mild cognitive impairment
• Recommended when mild cognitive impairment is suspected
• Particularly useful when MMSE scores appear normal (24+ out of 30) despite cognitive concerns
• Shows high sensitivity (0.89) and specificity (0.75) for mild cognitive impairment 2

Mini-Mental State Examination (MMSE)

• The best-studied and most widely used instrument for screening cognitive impairment 1
• Good sensitivity (0.85) and specificity (0.90) at a cut point of 24 for dementia in community settings 3
• Limited by:
  • Educational and age bias (more false positives in older, less educated individuals)
  • Lacks sensitivity for mild dementia or MCI
  • Proprietary instrument (not free to use)
  • Only fair predictive value when screening unselected patients 1

Mini-Cog and Addenbrooke's Cognitive Examination-Revised (ACE-R)

• Both have diagnostic performance comparable to MMSE 2
• Mini-Cog: 0.91 sensitivity and 0.86 specificity for dementia
• ACE-R: 0.92 sensitivity and 0.89 specificity for dementia

Enhancing Diagnostic Accuracy

Combining Assessment Approaches

• Combining cognitive tests with functional screens and informant reports significantly improves case-finding 1
• For optimal assessment, use a combination of:
  1. Cognitive screening tool (MoCA preferred)
  2. Functional assessment
  3. Informant report

Functional Assessment Tools

• Functional Activities Questionnaire (FAQ) - detects dementia with sensitivity and specificity comparable to MMSE 1
• Disability Assessment for Dementia (DAD) - recommended for rapid screening of functional autonomy 1

Informant-Based Tools

• Ascertain Dementia 8 (AD-8) questionnaire - useful when patient cannot complete screening tests 1
• Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) - provides valuable additional information 1
• Neuropsychiatric Inventory (NPI-Q) - for behavioral and psychological symptoms assessment 1
• Mild Behavioural Impairment Checklist (MBI-C) - for personality and behavior changes 1

Important Clinical Considerations

When to Screen

• Routine screening of asymptomatic individuals is not recommended 1
• Assessment should be performed when:
  • Cognitive impairment is suspected based on direct observation
  • Patient reports concerns
  • Family members, friends, or caregivers raise concerns 1
  • Patient has elevated risk factors (stroke, TIA, late-onset depression, sleep apnea, etc.) 1

Common Pitfalls to Avoid

1. Relying solely on a single cognitive test - diagnosis should not be based solely on screening test results 1
2. Using inappropriate cut-points - MMSE accuracy varies with age and education level 1
3. Missing mild cognitive impairment - MMSE has poor sensitivity for MCI; use MoCA instead 1
4. Neglecting functional assessment - cognitive testing alone is insufficient 1
5. Overlooking informant reports - essential component for accurate assessment 1

Longitudinal Assessment

• Serial cognitive assessments over time (such as QuoCo curves) may help optimize accuracy for distinguishing dementia from normal cognition 1
• MMSE alone has limited value as a single-administration test for predicting conversion from MCI to dementia 4

Algorithm for Dementia Screening

1. Initial screening: Use MoCA as first-line screening tool (especially when mild impairment is suspected)
2. Functional assessment: Add FAQ or DAD to evaluate functional status
3. Informant input: Obtain information from a reliable informant using AD-8 or IQCODE
4. Behavioral assessment: If personality/behavior changes are noted, use NPI-Q or MBI-C
5. Consider follow-up: Plan for longitudinal assessment if results are borderline

By following this approach, clinicians can maximize the early detection of dementia while minimizing false positives and false negatives, ultimately improving patient outcomes through earlier intervention and care planning.